Healthy Results in Population Health

June 6, 2016 - When you drop your nursing home length of stay and your readmissions, you’re doing something right in population health terms. That’s because the aim of population health is to help patients manage their health conditions closely enough that they can stay at home safely. Lawrence General has a Population Health Team that has been working with physicians and post-acute care providers in the community to make meaningful change in the way we care for the patients we share.

And the results of that work are receiving national attention. Dr. Pracha Eamranond, VP of Population Health, Robin Hynds, Senior Director of Integrated Care, and others involved in our Population Health initiatives have been invited to speak at several national conferences this year, most recently in May at the Health Information and Management Systems Society (HIMSS) Conference in Boston.

“HIMSS was impressed by the infrastructure we have developed in transformation that, frankly, does not exist in most organizations,” Pracha observes. “That is, a mature, sophisticated Division of Transformation that can address value-based care effectively, as well as help plan for more complicated, future risk-sharing agreements, such as participation in a Medicaid ACO. In short, our Transformation team is more already doing what many organizations are still figuring out.”

Perhaps we are successful because we are small and nimble. Perhaps it’s our strong relationships with our post-acute partners. What impresses other hospitals and health systems at a national level is our ability to work together with “unrelated” community providers to share responsibility, quality goals and outcomes with us, and work together with our care managers to change well-established process to work more effectively for each individual patient. This kind of cooperation and the results we’ve been seeing in our community are ahead of the population health curve elsewhere in the country.

“People are most interested in how we have sought out partners and now have Memorandum of Understanding agreements with conditions of participation,” comments Robin. “Most people like how we have described a step by step approach for engaging our staff in a different way than in the traditional sense to manage population health both inside and outside of the hospital.

“The newest tools we have begun to leverage give us the ability to analyze patient data in more detail than ever before,” says Dr. Pracha Eamranond. “We can identify individual care providers who fall outside of the parameters for best practice care of chronic conditions, for example, and share best practice data with them to help drive changes in their practice. We can optimize lengths of stay in skilled nursing facilities, using data to help us be sure the post-acute care plans work for each patient.”

So, hats off to our Transformation Team for the great work they are doing on behalf of our patients. The great care we are providing, together with our community partners, is driven by care managers and others who are working across the continuum, and across the traditional boundaries between providers, to serve each patients’ individual needs.